OPERATIVE PROCEDURE: The patient was taken to the operating room
after receiving intravenous prophylactic antibiotics. She underwent general
anesthesia using Allen stirrups. She had sequential compression devices
functioning bilaterally. The perineum and lower abdomen were prepared and
draped in the usual sterile fashion. A Foley catheter was placed for bladder
drainage.

Examination of the suburethral vaginal epithelium revealed a small area of
Ethibond suture protruding just medial to the right periurethral sulcus. This
was grasped with a tonsil clamp and removed with gentle traction. Attention
was then turned to the large polypoid granulation tissue extruding from the
left periurethral sulcus. This sinus was irrigated with a large amount of sterile saline. The granulation tissue was removed and the area surrounding the sinus tract was then infiltrated with approximately 10 mL of 1% lidocaine with epinephrine. The sulcus tract was enlarged by making an
incision in the vaginal epithelium at the inferior aspect of the sinus tract
being careful to stay away from the urethra and bladder. The epithelial edges
were then grasped with Adair clamps and the sinus tract probed with tonsil
clamps. This brought more Ethibond suture down to the opening, and this was
removed with gentle traction. The remaining sinus tract was probed without
finding any further foreign material. At this point, a small area of the
endopelvic fascia overlying the left lateral aspect of the urethra was noted to
be open. This was oversewn with a figure-of-eight suture of 2-0 Vicryl. The
vaginal epithelial edges were then trimmed and then reapproximated with 2-0
Vicryl in a running non locking fashion. Hemostasis was visualized. Iodoform
gauze was used to pack the sinus tract leaving a small wick at the inferior end
of the vaginal wound.

Cystourethroscopy was then performed which showed an area of erythematous
plaque along the bladder base. Cystoscopic biopsy forceps were then introduced
to remove 2 small tissue samples from the area. The remaining bladder was
intact without any further lesions, erosions, lacerations or foreign material.
There was bilateral ureteral efflux noted from both ureteric orifices
confirming postprocedural ureteral integrity. The patient tolerated the
procedure well. All sponge, lap, instrument and needle counts were correct x2
per the nursing staff at the conclusion of the procedure. The patient was awoken and taken to the recovery room in stable satisfactory condition.

SuperCoder Posted 6 Year(s) ago

52204
59300-22-51
Documentation must be submitted with medical records.

Kelli Posted 6 Year(s) ago

Thanks Sanjit but 59300 is related to maternity. The above is not the case. Is there another code I can use?

Posted by
Kelli,
6 Year(s). There are 3 posts.
The latest reply is from Kelli.